It is so important to us that Kids Kamp is a safe place for everyone. Please read through these safety agreements with your child as they will be asked to personally agree to them before the program starts and if there is anything they are not prepared to agree to, they will not be able to stay.

1. I agree that I want to come to kids camp and heal from trauma which is affecting my behaviour and enjoyment of life.

2. I agree that I will not tell anyone anything about anyone else’s abuse or trauma that I meet during the week.

3. I agree that I cannot use my mobile phone, electronic games or other distractions while I am here as it may stop me from healing.

4. I agree that it is very important that no one behaves badly to another person, this means that if I am rude, hurt, bully or cause another person deep upset I may be asked to leave. However I can always come back another time as we understand that such behaviour comes out of fear.

5. I agree to help with cleaning the house for 30 minutes every day and to participate in the program.

Although this a camp for very young people sadly we do need to add that obviously drugs, alcohol or mind altering substances are not tolerated and anyone using such substances will be asked to leave immediately. Be assured this has never been an issue with this age group so far.

Name*

FirstLast

I agree with all of the key safety principles above*

Click in the box to indicate yes you agree and click Next to continue your registration

Please note: It's important that this is filled in with your child who will be attending the program. (THIS INFORMATION IS CONFIDENTIAL UNLESS DUTY OF CARE REQUIRES DISCLOSURE)

If there are any cultural or religious observances you adhere to, please speak with the facilitator on arrival to the program. Please fill in all of the below questions so that we can provide the best possible service to you.

Please nominate a secondary contact person in case we are unable to contact you or your first nominated contact.

Emergency Contact Name*

Relationship to Guest*

His / Her Phone Number*

Does your child take any medication?*

If 'Yes', please give a complete list of medications, dosages and times taken*

Does your child have any allergies or specific dietary needs?*

If 'Yes', please specify*

If you feel it would be helpful for us to know, please note any mental health diagnoses

Bipolar

PTSD

Depression

Anxiety

Dissociative Identity Disorder

Schizophrenia

Borderline Personality Disorder

Other - please specify on arrival

Does your child have any phobias/fears that you feel it would be best we know about?*

If 'Yes', please specify*

To enable us to help you better, you may wish to let us know the type of trauma your child is a survivor of:

Physical

Emotional

Sexual

Spiritual

Neglect

SRA

Poor Parenting

Bullying

Abandonment

Incest

Domestic Violence

Early Childhood Illness

Divorce of parent

Death of a parent and/or sibling

Child Refugee

Child in State Care

Torture

In the last 3 months, has your child experienced problems in the following areas?*

Moods

Eating or Appetite

Sleeping

Trouble thinking clearly; understanding or concentrating

Speech

Missing Time

Suicidal Thoughts

Self Harm

Self Neglect

Aggression or Violence

Threats to or from others

Legal or police issues

Is your child consciously aware of the trauma/abuse?*

Has any member of your family done a healing week before?*

Why do you feel your child needs to attend our program?*

What benefits do you believe your child will gain from attending the program?*

Is there anything else about the current circumstances in the life of your child that might be useful or helpful for us to know about?

Please answer the following questions:

PLEASE NOTE; Questions marked with an asterisk (*) are required.

For the parent/guardian to sign by filling out your name in the below box:

1. I understand that I will need to attend a session myself at Heal For Life on the first and last day of the healing program to best support my child. I understand that if I do not attend these sessions, my child may be refused to attend.

I also understand if my child is unable to participate in the group safely, then Heal For Life may have to ask them to leave the program early, in which case I will be available to collect my child.

I have read and understand all the information in relation to the healing program and explained the relevant information to my child

Please ask your child to fill in this question, as your child who needs to know what the program is about and be happy to attend.

Why do you want to come to Heal For Life?*

Name of Parent/Guardian

Your healing program will be con­firmed once you have sent your Initial Registration Fee payment.

PLEASE do not make any travel or work arrangements until you have received a letter or email confirmation from us.

Cancellation / Deferral:

We often have a waiting list for our programs. If you cancel, defer or do not come to a confirmed place this may prevent someone else from attending. Please tick that you have read and understand the following:

1. I accept that if I cancel or defer after confirmation has been received, my Initial Registration Fee is not refundable.

2. If I cancel/ defer within 7 days of the program start date I understand that I am committed to complete the payment option I have chosen as it will have prevented someone else from attending.

3. If I choose to leave the program or if I am asked to leave prior to its completion I understand that I am committed to complete the payment option I have chosen.

Yes*

I have read and understand the above cancellation/deferral details.

The following fee covers accommodation, all workshops and workshop materials during the program. Heal For Life is committed to making our program available to anyone in need regardless of current income. However we receive no Government funding and we wish to remain independent. We are very grateful to those who can afford to pay the whole fee.

We offer monthly payments to make it easier for you. If however you have any problems with any of these options please call us on 02 4998 6003.

The following fee covers 5 nights’ accommodation and all workshops during the program. We wish to keep our program as affordable as possible and trust you will opt to pay the fee that best meets your financial situation.

Please select one of the following:*

Upfront Payment*

Price:$ 1,500.00Quantity:

Pay via direct deposit:

Greater Building Society Ltd - Heal For Life Adult Centre

Account No 718253683

BSB 637000

Once we have received your initial registration fee and registration details, we can confirm your place in the program.

Sponsored places – on each programme we have a limited number of sponsored places which can cover all or part of the total fee - If this would better fit your financial circumstances please contact the Office.